The fake iron tumor.
Samuel G, Diaz-Mendoza J, Paidipaty MSB, and Ray C. The fake iron tumor. Chest 2017; 152(4):A721.
Pill aspiration is a common problem in the elderly patients population. Iron pill aspiration can create an airway obstruction and present as a hypermetabolic focus on PET imaging falsely mistaken for a tumor affecting the management plan if not early recognized CASE PRESENTATION: 63 year old female, recently diagnosed with thyroid cancer (not on treatment) presented to our clinic with dry cough, dyspnea, positional wheezes, episodes of chocking, she denied any fever or hemoptysis. Medication list included iron pills, pantoprazole, alendronate. She is a nonsmoker, with no environmental risk factors and no recent travels. PET/ CT showed FDG-avid nodule with narrowing of the distal bronchus intermedius and proximal right lower lobe bronchus. Bronchoscopy at the Bronchus Intermedius showed malignant obstruction with nodular lesions at the antero-medial wall with 80% narrowing due to extrinsic compression, right middle bronchus was narrowed by 50% and the right lower bronchus was narrowed by 30%. Biopsies taken from stations 4L, 4R and 7 were positive for reactive inflammatory reaction with granulation tissue, the samples were deemed inconclusive. On repeated bronchoscopy, the bronchus intermedius was 90% obstructed showing smooth shiny tissue, most of the obstruction was relieved on suctioning till the airway became 100% patent. Repeated Biopsy showed reactive endobronchial mucosa with abundant brown orange crystalline foreign material consistent with iron deposition. DISCUSSION: Iron pill aspiration was reported previously, our case is unique in that it illustrates an atypical presentation mimicking a tumor showing as a hypermetabolic lesion, FDG-Avid on PET scan which can be misleading specially in the setting of recent cancer diagnosis, raising the suspicion for metastasis. Unlike most foreign bodies, the iron pill disintegrates in the airway and biopsy may reveal iron deposits along with an inflammation months after the aspiration. Symptoms as cough and recurrent infections are usually persistent. Complications can be airway stenosis or trans-bronchial wall necrosis and erosion through the major arteries leading to fatal hemorrhage and death. Treatment is endobronchial with removal of the caustic substance and reestablishing the airway using balloon, laser, or otherwise. Prophylactic measures are aspiration precautions mandating swallowing in sitting positions or usage of the syrup form in patients at high risk of aspiration. CONCLUSIONS: Syndrome of iron pill aspiration can be fatal, also as in our case, it might be misleading in cancer staging and hence treatment plan in a potentially salvageable case. Early suspicion is the key to early diagnosis.